The impact of the COVID-19 pandemic on dental trauma attendance: a systematic review and meta-analysis

Abstract This systematic review and meta-analysis aimed to analyze the impact of the COVID-19 pandemic on dental trauma patient attendance. The study was registered in the PROSPERO system, using the CRD42021288398 protocol. Searching was performed in PubMed, Scopus, Web of Science, Embase, Lilacs, and OpenGrey databases, using the following keywords: “Tooth injuries,” “Dental trauma,” “Traumatic Dental injury,” and “COVID-19". We included observational studies evaluating dental trauma in the context of the COVID-19 pandemic. Quality assessment was performed using the Joanna Briggs Institute Critical Appraisal Checklist for Cross-Sectional Studies. Meta-analysis was performed in RevMan 5.4 software with Odds Ratios as a pooled measure of effect, with a 95% confidence interval, and using random-effects modeling. After applying the eligibility criteria, 32 studies were included for qualitative analysis, in which 10 were used to assess the frequency of dental trauma diagnoses in dental emergencies. Despite the decrease of visits during COVID-19, the analysis revealed no difference between the pandemic and pre-pandemic periods. Regarding the type of dental trauma, two of the studies revealed no differences for the periods before and during the pandemic. This study revealed that the COVID-19 pandemic has not impacted the frequency or type of dental trauma compared to previous periods.


Introduction
The COVID-19 pandemic has affected the world's population, causing significant impacts to health care.
Due to the aerosol transmission of the disease, health professionals, especially dentists, are more vulnerable and exposed to the risk of contamination.[3] Moreover, to prevent the contamination, restrictive measures also had to be imposed, such as distancing and social isolation, occasionally suspending elective dental care for a period and assisting only urgent cases. 4The main types of emergency in dental care are endodontic, surgical, traumatic, and infectious disease. 5,6aumatic dental injuries are a public health problem worldwide that affect a considerable proportion of the population, especially children and young adults.Such injuries vary according to tooth structure involvement, from simple enamel fractures to avulsion.Depending on the severity, a trauma may require urgent professional care, possibly resulting in an irreparable dental damage.9][10][11] Each treatment is performed in accordance with the need of the case.Thus, the variability of traumatic injuries determines the diversity of treatments, which can be categorized as endodontic (pulpotomy, pulpectomy), restorative, periodontal (splinting of teeth), surgical (extractions), or as pharmacological interventions. 6,12,13e COVID-19 pandemic has spread worldwide, bringing many challenges to Dentistry, especially in terms of the population's access to dental care after the restrictive measures.Due to the need for urgent dental treatment in some cases of dental trauma, it is essential to understand how the pandemic impacted the demand for care of patients who suffered dental trauma and were treated in urgent dental services.In this context, this study aimed to assess the impact of the current pandemic on dental trauma health care by carrying out a systematic review of the literature with a meta-analysis.

Methodology
This systematic review and meta-analysis was carried out in accordance with the PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 14 and the study was registered in the PROSPERO system, using the

Search strategy
In July 2022, searches were performed in the PubMed/Medline, Scopus, Web of Science, Embase, and Lilacs databases, without an year of publication or language limitations.Searches were also carried out in the Open Grey referring to gray literature.The elaboration of the search strategy (Supplementary material) was performed using Medical Subject Headings (MeSH) and their respective terms, combined with Boolean operators (AND, OR): "Tooth injuries," "Dental trauma," "Dental-alveolar trauma," "Traumatic dental injury," "Tooth fracture," "Tooth avulsion," "Tooth luxation," "Tooth concussion," "Tooth intrusion," "Tooth extrusion," "COVID-19," "COVID-19 pandemic".Manual searching in the manuscripts was performed to verify the included studies' references.

Eligibility criteria
Observational studies that evaluated dental trauma during and before the COVID-19 pandemic were selected.Of these studies, those that also presented data from the pre-pandemic period were used as controls for comparative analysis.Case reports, case series, letters to the editor, comments, editorials, and literature reviews were excluded.Furthermore, studies that mentioned craniofacial, maxillofacial, The impact of the COVID-19 pandemic on dental trauma attendance: a systematic review and meta-analysis J Appl Oral Sci.

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or dentoalveolar trauma, yet without specifying the damage to dental structures, were not considered.Clinical trials were not considered due to ethical limitations regarding exposure parameters.

Study selection
The study selection process was performed using the Rayyan software (https://www.rayyan.ai/).Files from each database were imported and duplicates removed.The initial step was selecting the studies by title and abstract, followed by reading the full-

Quality assessment
Quality assessment was performed using the Joanna Briggs Institute Critical Appraisal Checklist for Cross-Sectional Studies 15 by two independent examiners (DSC and IAFM).The responses to the items in the checklist were "yes," "unclear," "no," or "not applicable."The questions evaluated and their respective answers were assessed using the RevMan 5.4 software (Review Manager 5.4,The Cochrane Collaboration). 16

Meta-analysis
Meta-analysis was performed on the studies and presented comparative results in the pre-COVID-19 and COVID-19 periods for the frequencies of dental trauma diagnosed from the total number of dental emergencies.Subgroup analysis was also performed to assess the types of dental trauma in these same periods.The analyses and their respective forest plots were performed using the RevMan 5.4 software (Review Manager 5.4,The Cochrane Collaboration) considering odds ratios (ORs) as a pooled measure of effect, with a confidence interval of 95%, and using a random-effects model.

Results
Figure 1 shows the flowchart of the study selection process following the PRISMA guidelines.Initially, 643 articles were identified in the databases, 337 duplicates were removed, and 306 studies were maintained for the title and abstract reading.After excluding 246 articles, 57 full-texts were read to verify the eligibility criteria, and 25 were excluded with justification (Supplementary material).No further studies were included, which may be a result from database searches originated in references.Thus, 32 studies were included in qualitative analysis, and 12 articles were included in quantitative analysis.
Figure 2 shows the information extracted from the selected studies.The studies were carried out in 13 countries (Qatar, Saudi Arabia, England, United Kingdom, Italy, Switzerland, Israel, India, China, Germany, Russia, United States, and Romania).
Only two studies 9,31 mentioned the affected teeth, presenting higher prevalence of the anterior teeth in the maxillary arch.The cause of trauma was evaluated by four studies, 9,10,31,35 whether falls or trips, bicycle accidents, assaults, traffic accidents, interpersonal violence, sports accidents, etc.
Figures 3 and 4 show the quality assessment.
The criteria evaluated in questions 1, 2, 3, 4, and 7 were present in all studies.The questions related to confounding factors were not applicable to the selected studies.4,30,36 R e g a r d i n g q u a n t i t a t i v e a n a l y s i s , 1 0 studies 5,6,22,26,28,33,35,37,39,41 were included to assess the frequency of a dental trauma diagnosis (Figure 5), with odds ratio of 0.76 and confidence interval from 0.52 to 1.12.Despite a lower number of dental emergencies during the pandemic, meta-analysis presented no statistically significant differences in dental trauma between the pre-COVID-19 and COVID-19 periods.However, a considerable level of heterogeneity obtained by the I 2 test indicated that the studies included were heterogeneous (I 2 =84%) in their reported effect size.
For subgroup analyses that classified dental trauma (Figure 6), all participants in the two studies 9,10 included experienced traumatic dental injuries.
The meta-analysis results presented no statistical differences by type of trauma in the evaluated periods, with only moderate heterogeneity (I 2 =41%), odds ratio of 1.15, and confidence interval of 0.80 to 1.65.The impact of the COVID-19 pandemic on dental trauma attendance: a systematic review and meta-analysis 8/15 trauma in the COVID-19 period was without statistical heterogeneity (I 2 =0%).

Discussion
This study presented no differences in the frequency of dental trauma diagnosed in the total number of dental emergencies between the evaluated COVID-19 pandemic period and the pre-COVID-19 period.Likewise, we observed no differences in the subgroups by type of dental trauma in these same periods.
Most of the studies included presented high quality assessment.The studies showing moderate quality lacked reporting statistical analysis.We did not apply criteria on identification and strategies dealing with confounding factors in the included studies, since the articles did not mention (and did not find) variables that could influence a diagnosis of dental trauma.
The COVID-19 pandemic had repercussions on all the health services, especially in dental care regarding dental trauma and urgent care, which continued CAMPOS DS, MUNIZ IA, GOMES AC, BESERRA LR, SANTOS LE, BATISTA AU, GOMINHO LF, SALAZAR-SILVA JR, D'ASSUNÇÃO FL working during the pandemic. 4In this study, we observed a worldwide concern regarding the care of patients with dental trauma, with studies carried out in emergency services in many countries, including the United Kingdom, China, India, Saudi Arabia, and Germany.
Dental trauma is a public health problem and requires activities such as planning, intervention, prevention, management, and considering the causes of trauma.Dental trauma needs further study to assess frequencies and factors involving sex, age, and type of trauma.This study presented a predominance of dental trauma in male patients, as previously reported in the literature. 8,43The literature reports greater involvement of children and adolescents in dental trauma, with a large age range. 44,45In this systematic review, 12 studies 6,13,18,24,26,27,[30][31][32]38,40,41  The most affected teeth by trauma are the upper central incisors, due to their vulnerability, i.e., their position in the arch. 46,47 Ths was also revealed in the two primary studies in this review, which reported the highest trauma frequency in maxillary anterior teeth, both in primary and permanent dentition.9,31 Traumatic injuries involve damage to dental structures and may affect the crown and/or the root of the dental element, which are associated or not with damage to the support structure, and may cause dislocations, avulsion, or alveolar fractures.48 Due to the diversity of impacts that can occur, treatment of dental trauma presents great variability.The patient requires adequate diagnosis, planning, case follow-up, and the most appropriate guidance for treatment.31,48 Dental pulp involvement is an important factor that guides decision-making, and must be correctly diagnosed, whether at the time of trauma or not, since intervention is not always immediate endodontics.49 Imaging exams are also important diagnostic tools to verify the involvement of dental structures and the extent of injury.48 After evaluation and diagnosis, the appropriate treatment must be offered as soon as possible, especially in cases of major structural damage, such as coronary fractures with pulp exposure, dental dislocations, and avulsion, which are types of dental emergencies. Time s a crucial prognostic factor to reduce the chance of pulp necrosis or an early loss of the affected tooth.[49][50][51] Knowledge is also essential for correct management of trauma and treatment success.One study performed by a questionnaire for dentists revealed the need to improve the professionals' knowledge about dental trauma management, especially avulsion.52,53 Likewise, health professionals presented insufficient knowledge concerning traumatic dental injuries.][54] To minimize this problem, one study proposed a dental trauma course for medical students, which yielded wide acceptance by students and positive perceptions for their future professional careers.55 Another strategy used for the implementation of teaching about dental trauma while still in graduation Due to the wide dissemination of the SARS-CoV-2 virus, in some dental services there was a need to assess priority emergency care and teledentistry was a good strategy.57 Teledentistry is a viable, accessible, and low-cost alternative 58 that some of the studies included 19,23,24 as a way to initially assess the patients, to provide guidance, such as counseling and drug-prescriptions (only analgesics/anti-inflammatory drugs), and to screen for clinical evaluation, since not all dental trauma cases are urgent and some can be managed remotely.although aerosols can be produced, this does not increase the risk contamination to professionals, as no contamination was reported during the studies cited.6,59 Studies that assess dental trauma in the context of the COVID-19 pandemic are of great relevance.
CRD42021288398 protocol.The following research question guided the study development: "What is the impact on demand for care of patients who suffered dental trauma and were attended in urgent dental services?"From the PECOS strategy: Population -P: Dental trauma patients; Exposition -E: COVID-19 pandemic period; Comparison -C: Pre-pandemic period; Outcome -O: the impact of the COVID-19 pandemic on dental trauma attendance; Study design -S: Observational study.
text of each potentially eligible article.Articles that did not meet the selection criteria were excluded with justification.Study selection was performed by two independent reviewers (ACG and LRMB) and disagreements were resolved by a third reviewer (DSC).Data extraction Data extraction from the included studies employed a standardized collection form with the following information: author, year, country, period, sample characteristics, dental trauma, tooth affected, cause of trauma, and treatment.The data extraction was performed by three reviewers (DSC, IAFM, and LEDS) and revised by a fourth reviewer (FLCDA).
carried out in emergency dental services provided to children/ adolescents from 0 to 21 years old.The other studies were performed in dental centers for the general public, with an age range from 0 to 95 years old.Dental care patients observed were mainly males in both the pre-COVID-19 and COVID-19 periods.

Figure 1 -
Figure 1-Flow diagram of literature searches in accordance with PRISMA 2020

Figure 2 -Figure 3 -Figure 4 - 15 J
Figure 2-Data extracted from the included studies

Figure 5 -Figure 6 -
Figure 5-Forest plot summarizing the frequency of dental trauma diagnoses in dental emergencies during the pre-COVID-19 and COVID-19 periods Teledentistry does not replace face-to-face care due to the need to carry out a careful clinical examination, with palpation and percussion tests, as well as complementary exams such as the acquisition of radiographs to obtain an accurate diagnosis.Despite the risks of transmission of COVID-19 in the dental environment, face-to-face care is necessary and must be available in emergency services with the use of adequate PPE by the entire dental team to protect health professionals and prevent the transmission of SARS-CoV-2.It has also been shown that when the appropriate PPE is used and biosafety protocols are implemented during emergency dental care services, Knowledge of this condition allows elaborationof preventive assistance strategies based on the population's needs, allowing better targeting of care and better clinical case resolution.Despite their importance, certain critical details remained unreported in various studies including: the type of dentition (deciduous or permanent), the most affected dental element, and in cases of trauma; the causes and treatments performed.This made it difficult to compare the results.Some studies included data on dental trauma as associated with other emergency conditions, making it impossible to use the information.Moreover, for being emergency services, samples were obtained by convenience, and according to the demand of the service, with no sample calculations performed; an intrinsic limitation in primary studies.Thus, future studies with better detailing of such characteristics, and allowing comparative analyses remain necessary.ConclusionBased on the present findings, this study revealed that the COVID-19 pandemic has not impacted on the frequency or type of dental trauma compared to previous periods.Further well-designed studies should be conducted to evaluate the particularities involved in patients who suffered dental trauma to help guide educational and preventive health care strategies for the most affected populations, optimizing planning and interventions.

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